A Good Death, by Michael Grosso PhD

Is the idea of a "good" death oxymoronic? Not according to hospice nurses I’ve been talking with. Their job is to facilitate a patient’s dying; they can observe things that most of us never can observe.

"A patient I’ve been tending died this morning," said Maryann. "There was some struggle, but in the end it was a good death." Maryann was one of five nurses who works at the Piedmont Hospice in Charlottesville, Virginia. A good death?

What makes a death "good" is still unclear, even mysterious, but some of the variables are coming into focus. The person who died that morning, for instance, seemed to sense the point when family members had finally come to terms with his death. It sometimes seems that patients adjust the timing of their death to coincide with family members reaching emotional closure. I have heard tales of saints and Zen masters predicting the exact moment of their death, but apparently even ordinary people can sometimes control the timing. Any element of control introduced into the dying process must count as good.

Other reported observations may help us formulate an idea of a good death. Some are unusual. For example, in the story mentioned above, during the last hours of the patient’s life, his dog climbed onto the bed, snuggled next to him, and remained immovably there until the man died. The dog could not be budged, and shared in the vigil of its master’s passing.

Other puzzling observations have been recorded. Occasionally there are sudden transformations, both in personality structure and even in physical appearance. A witness (not a nurse) reported to me observations of the final hours of her landlady, an elderly woman who was consistenly irascible prior to the onset of her fatal illness. She underwent a completely benign change of personality just before her death. What also amazed this witness was that the dying landlady looked twenty years younger and seemed radiant.

Dying patients sometimes have visions. They stare persistently at a corner of the room, light up with joy, become serene, and carry on conversations with invisible persons they name and address, usually deceased relatives. Visions of the dying have been documented in cross-cultural studies by psychologists. Having visions are clear markers of good deaths, according to some hospice nurses I spoke with.

They were also unanimous about what they called a "sacred" element that sometimes emerges in the terminal stages of life. Any sense of the presence of the sacred deserves to figure in the concept of a good death, but of course we have little reliable information about how it works, or what this undeniable quality of certain experiences really signifies. Whatever we ultimately choose to make of it, it’s an important dimension of a basic human experience.

I listened to the hospice nurses who were kind enough to share, not just their tantalizing observations, but their lively good spirits. (I stupidly anticipated they would be gravely dour.) Instead they seemed to me like excited astronomers who had observed signs of possibly unknown worlds. In fact, I think that careful scrutiny of the stranger phenomena is warranted, in spite of mainstream science’s shyness in the face of anything that smacks of the paranormal..

For example, the following was recounted to me. A small girl was present at her grandma’s death. At the moment of death the girl began to stare fixedly at something that appeared to be rising from her grandma’s bed toward the ceiling. The girl kept looking and addressed her grandother whose apparition apparently rose to the ceiling and vanished. The stories get curioser and curioser.

Nurses and their aides are more likely to have personal contact with dying patients than physicians, so they are more likely to observe these oddities. There is, moreover, tension between hospice workers and physicians who might view the hospice phase of a patient’s illness as advertising their failure. After all, a doctor’s job is to prevent death.

But death is a part of life. In dying, a new sphere of experience comes into play for the patient, which is beyond the reach of medical intervention, but no less real and important. It may be that only during the final phases of life that reveal the factors that constitute a good death.

Do we really need to look at this? According to empirical studies, the prevailing view of end-of-life is said to be "cognitively depressing." The idea of death suggests the total bankruptcy of meaning. The remarks of hospice nurses—and other privileged observers—point to data that seem to countervail this cognitive depression. They point to an opportunity to reframe the whole concept of death.

One kind of story I’ve heard from nurses adds significantly to the pattern in question. As many of us know from experience, brain disease in the elderly seems to destroy memory. Reports, however, exist since the mid 19th century of people with brain disease who recover their memories just before death. Most hospice nurses seem to know about this phenomenon. It looks as if the memories might be intact after all.

There is a moment, it seems, when consciousness disengages from the diseased brain housing it, and begins to recover its functions. This would be a fact with implications for our view of death. What they show is that our memories—the core of our personalities—are not annihilated by brain disease; they are, however, made inaccessible. It’s not that there is no one at the other end of the line; the problem is with the connection. With this we have another ingredient in our nascent picture of a good death. Anything that demonstrates the resurgence of mind at the moment of death is importanly positive, and life-affirming, in short, good.

When I ask folk in a position to make these end-of-life observations what they think enables a good death, they mention two things. The first is having a spiritual outlook. At first I thought they meant going to church, professing a creed, but they were emphatic about this not being the case. They insisted on distinguishing between the spiritual and the religious. The former is inwardly felt, the latter is behaviorally correct.

Unfortunately, to accept death in our culture is not easy. But what allows the good death to happen is to accept, to trust the dying process, to have a genuine feeling of openness to something transcendent. And this is less a function of religion than it is spiritual understanding. For those who cannot accept, cannot bring themselves to surrender to their experience, death is agonal — a quasi-technical term.

My uneasiness at this frightening idea was slightly assuaged by the second point The chances of a good death are increased if the dying person is supported by loving company. A good death is sociable, and other people being fully present to the dying person is basic.

But this can be hard for those who havn’t accepted their own mortality. Modern hightech hospitals keep death at a safe distance, and old-style family vigils by the deathbed are no longer fashionable. Instead we rely on technology to resist death at all costs. The idea of a good death isn’t oxymoronic; it’s just buried under the heavy machinery of modern medicine.

Michael Grosso teaches philosophy at the University of Virginia, and is the author of Experiencing the Next World Now (2004) [Paraview Pocketbook-Simon&Shuster], which is available from Amazon US and UK. More information about Michael Grosso is available from his personal website.

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Anonymous's picture

Great essay! Where I live, in Bali, Indonesia, death is a celebration. Cremation ceremonies are full of life, love, music, and good feelings. Balinese do often cry, either at a cremation or at a loved one's moment of death, (despite what Lonely Planet, or the Discovery Channel might tell you), but by and large they see death as a good thing. A golden opportunity to move on.

The ultimate goal for a Balinese is to be sufficiently spiritualy evolved to pull of "Moksa" - actually picking/predicting the moment of death, and leaving the world consciously at that moment. (Uh, suicide doesn't count) The great artist Nyoman Lempad, from Ubud, is said to have done this, and I have heard of others who have done it.

When my sister died a few years ago of cancer in the U.S., my mother was astonished at how difficult the funeral home made it for her to participate in my sisters cremation, although they gave in at the end. What a pity, and how telling of the West's attitude.

Dashour